The Strange Happiness of the Emergency Medic

There is your life before the truck, and there is your life after the truck. An apprenticeship with paramedics shows what it really means to have a bad day. PLUS: Learning how to be a DIY chef and a plumber

My first body came on my first shift. It was a Friday night, dark and cold, the wind whipping across the empty fields. We were at a rollover on a country road. Someone had drifted too far into the snow on the shoulder and gone into a ditch. There had been two occupants, but somehow they were fine, not a scratch on them. On the way back to the ambulance — here in Ottawa, the paramedics call them trucks — we stopped to look inside their car, which was still on its roof. There were two barbells that had banged around in there and settled on the ceiling. We were ducking our ears into our coats and talking about how lucky the people were not to get brained when the radio squawked.

Serving a region with a population of just over one million, the Ottawa Paramedic Service answered more than 103,000 calls last year. The calls come over the radio in bunches. In my first five minutes inside the truck, there were calls for a woman having a seizure in a grocery store, an eight-week-old boy choking, a homeless man found unconscious in an alley, an elderly man with difficulty breathing, a possible heart attack in a chicken restaurant. If you just sat inside that truck listening to the radio, you'd believe the world was falling apart. It's madness. But even in the midst of all that screaming and chaos, there are calls that stand out. A Code 4 is a life-threatening emergency, lights and sirens. A Code 4 VSA — vital signs absent — is lights and sirens and a little bit more. This call was a VSA, a woman stretched out in the darkness to our west. Darryl and I jumped into the truck and bucked it.

Darryl Wilton was my mentor and partner. He's thirty-six, tall with a shaved head. If you could request a particular paramedic when you dialed 911, you would ask for him. He's been in the truck for twelve years, and he has seen a lot of things. As part of my training, he showed me published and unpublished media photographs from some recent calls to make sure I had the stomach for the work. He didn't want to have to treat me, too. ("The barrel-over-the-falls effect," he called the bilious uprush that rookies suffer.) There was the motorcycle wreck in which a husband and wife were launched across an intersection like crash-test dummies. There was the poor bastard who had been pulled into a printing press by his right arm. That's when I was introduced to the term "degloving." The guy had lost every shred of skin from his fingertips to his shoulder. His arm looked like an illustration in an anatomy textbook, a collection of red muscle and white flashes of bone and ligament.

I understood there would be my life before I spent time in the truck and my life after. We raced through the night, and I tried to prepare myself. Darryl prepared, too, but in a different way. He switched his brain into its most methodical gear. It was almost as though he were treating patients in advance of seeing them. "Time is tissue," he said. With every minute that passes before treatment, more body parts that should be pink turn white or blue, and white or blue equals death. As we listened to updates on the radio, he'd ask me what I thought about what was coming, and he would gently guide me toward the likely reality. Code 4's that came in just after snowstorms were often heart attacks — someone goes out to shovel and his heart can't handle the exertion. VSAs early in the morning were often unworkable, because chances were that the victim had died in the night, hours before he was discovered. Then the Code 4 would become a Code 5. "There's clinically dead, which we can work with," Darryl said. "And there's obviously dead, which we can't."

We knew this woman was elderly and laid out in her garage. It was a little after 7:00 p.m., which gave us a few possibilities. It had been snowing pretty hard, so maybe she had a shovel in her hands. (Paramedic calls follow the seasons: Summer sees an increase in trauma; winter brings a spike in medical calls.) Or maybe she fell on a patch of ice and hit her head. Darryl worried that she might have gone down sometime in the afternoon and not been found until someone returned home from work. We both reached into the box between us and pulled out blue nitrile gloves.

Fence posts blurred by. It turns out the lights and sirens clear minds as well as traffic, the way boxers use entrance music. I became dialed in on the snowflakes caught in our lights. They froze in front of us like crystals hanging in the darkness, a thousand tiny flashes of red and white. There was something really, really beautiful about the snow, and I stared at it, and my breathing slowed, and when the voice on the radio came on again to say that we were likely heading into a Code 5, I was ready.

She was lying on the cement on her back, folded up impossibly small. Her knee was blown out, and she had thrown a slipper. Her face was waxy white, whiter than even her hair. Her eyes were closed and her mouth was open. She was also frozen nearly through.

She had been found by her son, who was now sitting in her kitchen. Another paramedic, Jennifer, sat with him; when the victim is a body, attention turns to the survivors. She explained what would happen next, trying to soften the coming blows. She told him the coroner would arrive and the shape under the tarp that had been his mother would be taken away by the city's body handlers. When the cops came, Darryl suggested calling the family doctor instead of the coroner to fill out the death certificate, because the house wasn't in great shape, so money might be an issue. (If the coroner does it, the body is taken to the morgue, and going to the morgue costs money. If the family doctor comes, the body can be taken straight to the funeral home, a cheaper and more compassionate avenue for the grief to take hold.) Darryl always looked past the purely medical issues like that. But the cops shrugged and put the body into the system anyway. We took off our gloves, and we walked through the snow back to the truck and began driving into town.

Without the lights, the snow was just snow again. We speculated about what had happened to the woman, constructing a diagnosis in reverse. Now none of the possibilities was good. "It's hard to know which came first, the fracture or the fall," Darryl said. We both hoped out loud that she had gone quickly, but we both knew she probably hadn't. The truck went silent. We needed the radio to spark us back to life. In Ottawa, they keep careful track of hourly call volumes and try to have just enough trucks on the road to meet the expected demand. That's to save money — a function of institutional efficiency — but it also keeps paramedics busy. It's always better to have the bad calls blur like fence posts.

Fortunately, a twenty-four-year-old man obliged us by not eating for two days before going to the gym and then sitting in a steam room for forty minutes. He had been found passed out in the locker room, Code 4. Darryl fired up the lights and sirens, and we stopped talking about the dead woman and started talking about volume depletion, low blood pressure, and how our first step would be to give him a full physical evaluation to make sure he hadn't done lasting damage to himself, followed by a big hit of saline from an IV.

In some ways, the human body is a deceptively simple machine: Air needs to go in and out, and blood needs to go around and around. Anything that interrupts those two processes is bad and must be corrected quickly. I was told again and again to remember the ABCs: airway, breathing, circulation. That's the essence of emergency medicine. The problem is, there are hundreds of reasons why the ABCs stop working.

Take the heart. It's a pump. A heart attack stops it from pumping, which means blood isn't carrying oxygen to the brain, which means the brain dies, and the brain can't repair itself or be brought back to life. It's pretty simple math. But there are several types of cardiac arrest, and each needs to be treated differently. Some cause the heart to flatline, like we've all seen on TV. We've also seen the TV doctors shock a flatlining patient with paddles, but that's not the way it works. In reality, the paddles are used when someone's heart is beating too fast or fibrillating and needs to be shocked into a normal rhythm. CPR won't restart a heart, either. CPR saves lives — it really does, no joke — because pumping on someone's chest will generate enough blood flow (though only about 16 percent of the heart's normal stroke volume) to keep the brain alive until help arrives. But only seriously toxic medications such as epinephrine, atropine, and dopamine will coax a chugging heart to start beating properly again.

The drugs were in the big blue bag. It's the portable pharmacy in the portable emergency room, and it came in with us on every call. There's glucagon and dextrose for diabetics, morphine and fentanyl for pain, naloxone for narcotic overdoses, and a couple dozen other medications. Three more pieces of equipment were carried on every call, no exceptions: a red bag containing an oxygen tank, an intubation kit, and a cardiac monitor. The truck was also stocked with trauma bags filled with dressings (orange), a bag that contained resuscitation equipment for infants (light green), and a spinal bag with restraints and collars (dark green). The appearance of those bags on a scene meant something very bad had happened.

Before my first shift, I worked my way through the bags with a paramedic named Suzanne Noël. It was impossible to cover everything that might happen on a given shift — broken bones, strokes, childbirth, heart failure, brain injury, gunshot wounds, stab wounds, toxic shock — or where the drama might take place: in a bedroom, a bar, or a car upside down in a ditch. It's a job that requires a free kind of spirit, and like most paramedics I met, Suzanne was bright-eyed and quick to smile. "Seeing what we see, we know how lucky we are to be alive," she said.

It was one of the great lessons of the truck. I expected to find a bunch of burnouts dragging through the graveyard shift, broken men and women who dipped into the blue bag so they might find sleep. But paramedics are a surprisingly sunny bunch. They understand that it's all so much randomness anyway, a cosmic confluence of vectors. One night, four kids got into a car and raced down the slushy streets until the driver lost control. The car spun like a roulette wheel before it was finally stopped by a streetlight. One kid, unlucky enough to have chosen the seat that ended up with the streetlight in it, suffered massive head injuries. The other three walked away. They knew the out-of-body feeling that follows the cheating of death, the feeling that every day between that day and their last will be a gift that so easily could have gone unopened. Paramedics know that feeling better than anyone, because they walk out of nightmares unscathed again and again. They know what a genuinely bad day really looks like, and they know that day will come for them, too, but today is not that day, and that knowledge alone was reason enough for Suzanne to smile.

With Suzanne's guidance, I intubated a dummy over and over until I stopped breaking its teeth, I calculated doses of medicine based on patient weight and time of delivery, I pulled a coin out of a dummy's throat with a pair of McGill forceps, and I learned to read ECGs and spot the difference between ventricular fibrillation and torsades de pointes. (Ottawa paramedics are among the first in the world to be trained to diagnose 12-lead ECGs. One type of heart attack, a STEMI, creates a wave pattern the paramedics call "tombstones"; a patient diagnosed with a STEMI is delivered straight to the heart surgeon, bypassing the emergency room, to undergo an angioplasty.) Unlike services in many American cities, the Ottawa Paramedic Service requires each recruit to have finished two years of college-level education in health sciences and two to four more years in paramedicine, as well as spend at least 480 hours in the truck. These aren't the junkie mercenaries from Bringing Out the Dead.

The calls never let up, and they were never the same thing twice. Darryl has answered thousands of calls in his career. Some have been burned into his memory by the noise and blood. He remembers the woman who fell in her shower and carved out her iris on a ceramic tile; he remembers the guy whose hand was shredded in the gears of a cement mixer and was still screaming after 400 micrograms of fentanyl. He told me that at car wrecks he sometimes has to count extremities to figure out how many people were in the vehicle. "Once I thought I was dealing with one body until I found two left hands," he said. Other calls stand out because of how quiet they were. He talked about the thirty-two-year-old new mom who was dying of breast cancer; he talked about consoling the parents of a seventeen-year-old boy who had just committed suicide. I'd listen to his stories and ask him to make sure he had some midazolam ready for me. It's a powerful sedative that also makes you forget.

But deep down, I didn't want to lose a moment of my time in the truck. After each shift, I'd go home and pour myself a drink or two and catalog the things I could remember. They were not the things I might have expected. We had life-and-death calls that disappeared the moment I left the scene, washed away by the adrenaline; we had routine calls that for whatever reason hung around and kept me awake for hours.

"You never get immune to that," Darryl said. He can't look at Elmo dolls anymore because of a child VSA call he had.

We had a young diabetic woman go hypoglycemic — she had a blood-sugar level that would have knocked out most of us — because she and her boyfriend just couldn't afford food. "We have two days till we can shop again, so our cupboards are pretty bare," the boyfriend said. At one cardiac call, I can remember a frying pan on the stove filled with still-sizzling green peppers and onions. And there was the trio of college students who had each managed to drink thirty ounces of vodka in about as many minutes. After the students had been bundled to the hospital and pumped clean, some rookie paramedics talked about how they'd never seen puke on a ceiling before.

But the call I remember most came on my last shift. It had been a relatively slow morning, a Monday, the city just coming back to life after a long winter's night. We were at an asthma call when we heard a Code 4 VSA crackle: an old man found by his son on his living-room floor. Darryl and I hopped into the truck and began pushing through the awakening streets. I remembered what Darryl had told me about early-morning VSA calls, and I reached again for the blue nitrile gloves.

The GPS brought us to a stretch of attached homes, small and a little run-down. Another paramedic team, Marc and Pierre-Paul, had just beaten us to the address; their truck was pulled up into the snowbank outside one of the units, the lights still flashing. We grabbed our bags and ran up the icy front walk. The son was at the open door, standing in the cold. Inside, the house was still dark, the curtains drawn.

It smelled like sickness. There's a smell in houses where death has come or is on its way. It's like vinegar, like piss, plus dog kibble, plus cheese. It hits you as soon as you walk through the door. I had smelled it when we had walked into that garage, and I smelled it in this house.

He was stretched out on the floor; the carpet was brown. There were lots of certificates and awards on the walls. There were some new ones on the couch, framed but waiting to be hung — won by his children, maybe grandchildren. The old man was shirtless, exposing his big barrel chest, and he was barefoot, his toes pointed skyward. He was pale and cold to the touch. He had been there for a while, probably hours. He had crept downstairs in the middle of the night for a glass of water or to take a leak and here he was, stopped in his tracks. He looked Code 5.

Yet suddenly, a pulse. Marc and Pierre-Paul had poured the epinephrine, atropine, and dopamine into him, and now a heart that wasn't really beating had started up again, however faintly. Trauma patients are rushed to the hospital, but every other patient has to be stabilized before transport. So we kept working on the man on his living-room floor, watched over our shoulders by his son. Darryl asked him if his father had heart trouble, and the son said he didn't think so. He went upstairs to look in his father's medicine cabinet. "It looks like he's been holding out on us," the son said, sounding numb and detached as he returned with a half-empty bottle of bright-red nitroglycerin.

The defibrillator was fired up and the ECG leads attached to the old man's chest and, sure as shit, beep beep beep. Now the blood was going around and around, but the air still wasn't going in and out. We worked the laryn-goscope into his dry mouth and held his tongue out of the way before sliding the intubation tube down his throat, between the bright-white goalposts that were his vocal cords. A bag valve was attached to the tube. It looks like a clear plastic football and has to be squeezed manually every four or five seconds to push in the air. It's a strange sensation, knowing the only thing keeping a man alive is your blue hands and a piece of plastic.

At last the old man was not only alive but stable. We covered him with a blanket and moved him into the truck, now watched by neighbors in their nightgowns as well as the son, and we continued to squeeze the plastic football. We worked all the way to the hospital, shouting over the sirens, and we worked as we wheeled him into the operating room, where the doctors were waiting. We gave the old man to them, and we went outside and shivered for a second before we went to the next call.

I came home after, and I was supercharged. My wife asked me what we had done, and I told her we'd saved a man's life. We turned his heart back into a pump and his lungs back into oxygen tanks. He should have been another body on another floor, but instead we watched him turn from white to pink in front of us, and then we watched some very small things happen, the things my time in the truck taught me never to take for granted: He swallowed, he turned his head, and then finally he opened his eyes and looked straight at me. His eyes were blue, like mine, and they were wet in the bright light in the back of the truck. And then, talking to my wife, my eyes were wet, too. I am a father and a son, and that day, we had given a son back his father.